Implementation of the BLS Ambulance Pilot Program and the One and One Response Program

Two of the goals of the merger between Emergency Medical Services (EMS) and the Fire Department in 1997 were reduction of Advanced Life Support (ALS) ambulance response times¹ to medical calls and improved services to neighborhoods with high medical call volume.

Subsequently, to further address these goals, the Department implemented a 24-month pilot program to deploy Basic Life Support (BLS) ambulances to respond to less emergent (or Code 2) medical calls² and has proposed implementing a "One and One" Response Program, deploying both ALS ambulances and ALS engines.

BLS Ambulance Pilot Program

The BLS Ambulance Pilot Program was intended to improve resource allocation by dispatching BLS ambulances to Code 2 calls, which make up approximately 40 percent of all medical calls, and to decrease workload for ALS ambulances in neighborhoods with high call volume. By deploying BLS ambulances, the Department hoped to free-up ALS ambulances for more emergent (or Code 3) calls and to reduce ALS ambulance response times.

The BLS Ambulance Pilot Program was implemented from January 1999 until January 2001. Under the pilot program, the Department deployed four BLS ambulances staffed with two firefighter/emergency medical technicians (Class H-2), and 16 ALS ambulances staffed with two paramedics (Class H-3 firefighter/paramedics and Class H-1 fire rescue paramedics). In addition, the Department deployed approximately two 10-hour ambulances, staffed by civilian paramedics (Class 2532)³. A twelve-month report prepared by the EMS Division concluded that "BLS ambulances staffed with EMTs (emergency medical technicians) can respond to a limited number of BLS-level calls and safely and appropriately assess, treat and transport these patients".⁴ Although the EMS Division found that BLS ambulances could safely provide budanalyst, treatment and transport, the BLS pilot program was terminated in January 2001 primarily due to deficiencies in dispatching and quality assurance concerns.⁵

One and One Response Program

When the Fire Department proposed implementation of the BLS Ambulance Pilot Program, the Department identified increased volume of medical calls as a significant problem for the EMS system.⁶ At that time, the Fire Department evaluated three possible solutions to increased workload resulting from increased medical calls, including utilization of private ambulance companies, deploying BLS ambulances (discussed above), and implementing a One and One Response Program.

The Fire Department implemented the initial phase of the One and One Response Program on January 5, 2002. Under this program, the Department would deploy 19 ALS ambulances staffed with one firefighter/paramedic (H-3) and one firefighter/EMT (H-2), and 25 ALS engines staffed with one paramedic (H-3), two firefighters (H-2) and one officer. The Fire Department will also deploy 10-hour ambulances, staffed with civilian paramedics (2532) and fire rescue paramedics (H-1). On January 5, 2002, the Department converted four ALS ambulances, six ALS engines, and six ALS trucks as part of the initial phase of the One and One Response Program.⁷ Currently, the Department deploys 20 ALS ambulances staffed with two paramedics (H-3 or H-1), 6 ALS engines and approximately two 10-hour ambulances.

The Department intends that the implementation of the One and One Response Program will address specific EMS problems, including the failure to meet recommended ALS response times, high paramedic workload, inability to complete firefighter field training experience for new firefighter/paramedics, and relatively high firefighter/paramedic attrition rates.⁸

Table 4.2.1
Comparison of Current Daily EMS Daily Staffing Model and Proposed Daily One and One Response Staffing Model

^* The Department currently schedules one to two ambulances for 10-hour shifts based on available staff. The proposed one and one staffing model would increase the number of 10-hour ambulances from the current staffing level of one to two 10-hour ambulances per day to approximately four 10-hour ambulances per day. Under the proposed one and one staffing model, the Department proposes to deploy 10-hour ambulances during both day shift hours (approximately 7:30 a.m. to 5:30 p.m.) and evening shift hours (approximately 5:30 p.m. to 3:30 a.m.).

Implementation of the BLS Ambulance Pilot Program and the One and One Response Program to Address Problems in Delivering EMS Services

Both the BLS Ambulance Pilot Program and the One and One Response Program were intended to reduce EMS workload, resulting from an increased volume of medical calls. When the Department implemented the BLS Ambulance Pilot Program, the Department stated that increased medical call volume and uneven distribution of medical calls by neighborhood contributed to problems in delivery of EMS services. In proposing implementation of the One and One Response Program, the Department has stated that high paramedic workload is a problem in service delivery. Additionally, the Department has proposed implementing the One and One Response Program to address service and staffing problems, including the failure to meet recommended response times, inability to complete firefighter field training for new firefighters/paramedics, and relatively high firefighter/paramedic attrition rates.

Increased Medical Call Volume

From calendar year 1998 through calendar year 2000, medical call volume increased by 3.16 percent, although medical call volume actually declined slightly in calendar year 1999 compared to calendar year 1998. During this period, the Department increased the number of ambulances deployed daily from 17 to 20.5, or 20.59 percent, and the number of full-time equivalent (FTE) positions available for EMS calls from approximately 183 FTEs to 245 FTEs, or 33.9 percent.

In each of the three years, the number of ambulance dispatches exceeds the number of medical calls. According to the Fire Department, an ambulance is dispatched to all fires, resulting in an increase in the number of dispatches. In some instances duplicate ambulances are dispatched to the same medical call and to multiple injury accidents. As noted in Table 4.2.2, the ratio of ambulance dispatches to medical calls in calendar year 2000 is 1.11 dispatches per call. The total number of ambulance dispatches is increasing at a slightly higher rate than the total number of medical calls. The total number of ambulance dispatches has increased by 3.85 percent compared to an increase of 3.16 percent in medical call volume dispatches between calendar year 1998 and calendar year 2000.

Table 4.2.2
Summary of EMS Call Volume and Dispatch Data from
1998 through 2000

* The FTE count includes classifications 2532 Paramedic, H-1 Fire Rescue Paramedic, H-3 Fire Fighter Paramedic, H-33 Fire Rescue Captain, and other uniformed managers on June 30 of each year.

Distribution of Dispatches

According to documentation provided by the Department, ambulances deployed for 10-hour shifts are dispatched to more medical calls, when averaged by the hour, than ambulances deployed for 24-hour shifts. Based on the FY 1999-2000 CAD data, the average number of dispatches for 24-hour ALS and BLS ambulances was 9.61 dispatches in 24 hours.⁹ According to a memorandum prepared by the Department, the average number of dispatches for 10-hour ambulances for the six-month period from January, 2000, through June, 2000, was 6.3 dispatches in 10 hours.¹⁰

Ambulances deployed for 24-hour shifts are more restricted in their unit hour utilization (or the amount of time an ambulance is in service from the start of a call to the end of a call) than ambulances deployed for 10-hour shifts. According to the Emergency Medical Services Agency (EMSA), the industry standard for the unit hour utilization ratio for ambulances deployed for shifts of ten hours or more is 0.4. In a report prepared by the Department¹¹, the purpose of limiting unit hour utilization for 24-hour shifts is to allow for adequate sleep time and time for paper work, cleaning and restocking the unit, and eating. According to the report, "Lessor hour units can be held to a higher standard because of their definitive duty hours. Though still important, eating and sleeping become less important on these types of units". Under the Emergency Medical Service Agreement between San Mateo County and American Medical Response West, average unit hour transport ratios for ambulance crews regularly scheduled to work in excess of 12 hours can not exceed 0.4, or 9.6 hours per 24-hour shift. Under the San Mateo County Agreement, ambulances scheduled for 12 hours or less do not have any restrictions regarding unit hour utilization. Based on FY 1999-2000 data, the San Francisco Fire Department"s average unit hour utilization was 7.25 hours in 24 hours.

ALS and BLS ambulances deployed in neighborhoods with high medical call volume were dispatched much more frequently per shift than ambulances in neighborhoods with lower medical call volume, as shown in Exhibit 4.2.1. In FY 1999-2000, the average number of ALS and BLS ambulance dispatches for 24-hour ambulances was 6 dispatches per ambulance per shift at Station 29 and approximately 17 dispatches per ambulance per shift at Station 1.

Exhibit 4.2.1
Average Daily Medical Dispatch by Ambulances (ALS and BLS), Engines
and Fire Station in FY 1999-2000

The number of medical dispatches also varies by time of day. Although the Department deploys 20 ambulances on a 24-hour basis, the actual demand for ambulances is greater in the late afternoon and evening. As shown in Exhibit 4.2.2, dispatch volume during the daytime and evening hours is higher than during the hours between 12:00 a.m. and 8:00 a.m.¹² The number of medical dispatches varies less by day of the week, and is only slightly greater during the weekend than during the week.

Exhibit 4.2.2
Average Daily Number of Code 2 and Code 3 Ambulance Dispatches in FY 1999-2000 by Time of Day

Medical Call Response Times

The Fire Department uses ambulance response times as one criterion for evaluating delivery of emergency medical services, and gives reduction in ambulance response times as one of the reasons for proposing the One and One Response Program. Although the average number of ambulances deployed each day has increased from 17 per day to 20.5 per day from 1998 through 2000, the Department has not achieved its recommended response time of 10 minutes for Code 3 calls and 20 minutes for Code 2 calls, as shown in Table 4.2.3.

Table 4.2.3
Average Response Times for All Ambulances
for FY 1999-2000 and FY 2000-2001¹³

f

As shown in the table, average ambulance response times increased between FY 1999-2000 and FY 2000-2001. Code 3 ambulance response times increased by approximately one minute, or 9.6 percent, and Code 2 ambulance response times increased by 37 seconds, or 1.7 percent. As noted above, the Department has not yet determined average response times for the final 3 months of FY 2000-2001. Because engines are distributed at fire stations throughout the City, they are often first to arrive at medical incidents and generally have shorter response times than ambulances. For Code 3 calls, the average engine response time in FY 1999-2000 was 6 minutes and 38 seconds.

Costs Associated with Implementation of the BLS Ambulance Pilot Program and One and One Response Program

Estimated Costs of the BLS Ambulance Pilot Program

To staff the four new BLS ambulances, the Fire Department created 36 new firefighter/EMT positions at an annual salary and fringe benefit cost of approximately $2,471,851.¹⁴ Deploying four additional ambulances and creating 36 new positions resulted in ongoing increased costs to implement the BLS ambulance tier. Although the Department has terminated the BLS Ambulance Pilot Program, these four ambulances were converted to ALS ambulances with ongoing increased salary and fringe benefit costs.

Estimated Costs of the One and One Response Program

Although the proposed One and One Response Program does not create new positions, estimated salary and fringe benefit costs will increase by approximately $641,740, resulting from changes in the configuration of existing positions, as shown in Table 4.2.4 below.¹⁵

Effect of Increased Dispatches per Medical Call

As shown in Table 4.2.2, the number of ambulance dispatches per medical call increased from 1.06 ambulance dispatches per medical call in 1999 to 1.11 ambulance dispatches per medical call in 2000, a 4.3 percent increase. The ratio of all dispatches, both engine and ambulance, per medical call was 1.58 in 2000. Because the Department has fixed post staffing, which deploys a minimum number of apparatus and staff at all times, dispatching additional apparatus to medical incidents does not result in increased direct costs. However, dispatching multiple vehicles to each medical incident increases demand on Department resources, and could eventually lead to demands for increased staffing and associated costs. As noted previously, the Department dispatches ambulances to all fires and dispatches multiple ambulances to multiple injury incidents. Additionally, the Department dispatches engines as a first responder to incidents. Because the proposed One and One Response Program calls for the dispatch of an ALS ambulance and an ALS engine to medical incidents to ensure that two paramedics arrive at the incident, the One and One Response Program will likely result in increased dispatching of apparatus and staff to medical incidents. As part of the evaluation of the One and One Response Program, the Department needs to show that implementation of the program does not result in increased dispatching of ambulances and engines to medical incidents, thus increasing demand for Department resources.

Costs and Savings Compared to Benefits of BLS Ambulance Tier, One and One Response Program, and Other Alternatives

As noted previously, the Department implemented the BLS Ambulance Pilot Program and has proposed implementing the One and One Response Program to address (a) the failure to meet recommended ambulance response times, (b) increased medical call volume and uneven distribution of workload, (c) necessary firefighter and paramedic experience for fully cross-trained staff, and (d) attrition among firefighters/paramedics (H-3). The Fire Department has incurred increased costs for new positions but has not achieved its goals in reducing ambulance response times and uneven workload distribution.

Cost-Effective Alternative to the Department"s Proposed Implementation of the One and One Response Program

Under the current One and One Response Program proposal, the Fire Department would incur increased salary and fringe benefit costs of approximately $641,740 annually, based on the current staffing proposal for the One and One Response Program.

The proposed One and One Response Program is intended to reduce ALS response times by increasing the number of ALS units, whether ambulances or engines, deployed in San Francisco neighborhoods, and by dispatching ALS engines as a first response unit. As part of the One and One Response Program, the Department will increase the number of 10-hour ambulances deployed. Currently, the Department deploys 20 ALS ambulances on 24-hour shifts, 6 ALS engines, and approximately two 10-hour ambulances, depending on available staff. Under the proposed One and One Response Program, the Department would deploy 19 ALS ambulances on 24-hour shifts, 25 ALS engines, and approximately four 10-hour ambulances. Until now, the Department has generally deployed the same number of ambulances on a 24-hour basis, although medical call volume varies by time of day, as shown in Chart 4.2.2. Although the total number of Code 2 and Code 3 medical calls increases slightly during the weekend, overall the number of medical calls does not vary greatly by the day of the week. Other goals of the One and One Response Program include decreasing workload by increasing the number of available ALS units, both ambulances and engines, and increasing opportunities for paramedics who are newly-trained as firefighters to work on engines and for firefighters/EMTs to work on ambulances.

We find that the Department could reduce costs, without forfeiting the Department"s goals of reducing ALS ambulance response times, decreasing workload per ambulance, and increasing opportunities for Department staff to gain experience on ambulances and engines, by deploying ALS ambulances during the periods of greatest medical call volume and by deploying some BLS ambulances. As discussed previously, the BLS Ambulance Pilot Program was initially implemented to decrease ALS ambulance workload in neighborhoods with high call volume and to utilize resources more efficiently, by dispatching BLS ambulances to Code 2 medical calls, which make up 40 to 45 percent of all medical calls. The Department"s evaluation of the BLS Ambulance Pilot Program concluded that the BLS ambulances were able to safely deliver care for Code 2 medical calls. The deployment of BLS ambulances frees up ALS ambulances to respond to Code 3 calls and provides ambulance experience for firefighters/EMTs (H-2). To deploy the BLS ambulances, the Department would need to address concerns regarding the training of dispatchers to appropriately identify the need for BLS or ALS ambulances, improve quality assurance, and obtain legal advice from the City Attorney regarding the City"s liability under the Bronzan Act.¹⁶

The Department should deploy additional 10-hour ALS ambulances rather than 24-hour ambulances to cover the periods of high medical call volume. By deploying BLS ambulances and additional 10-hour ALS ambulances, the Department could increase the EMS resources available during the time of highest need and reduce costs.

Based on an analysis of the FY 1999-2000 CAD data of the number of ambulance dispatches to Code 2, Code 3 or life-threatening medical calls in a given hour, we recommend that the Department deploy sixteen 24-hour ambulances as part of the proposed One and One Response Program, rather than nineteen 24-hour ambulances, as the Department proposes. Of these sixteen 24-hour ambulances, we recommend that the Department deploy at least 13 of the sixteen 24-hour ambulances as ALS ambulances and that the Department consider, as a matter of policy, deploying three of the sixteen 24-hour ambulances as BLS ambulances. As noted above, the Department would need to address concerns regarding the training of dispatchers to appropriately identify the need for BLS or ALS ambulances, improve quality assurance, and obtain legal advice from the City Attorney regarding the City"s liability under the Bronzan Act to deploy the three BLS ambulances. In addition to sixteen 24-hour ambulances, we recommend that the Department deploy seven ALS 10-hour ambulances for the hours of greatest medical call volume between 8:00 a.m. and 12:00 midnight. Table 4.2.4 compares our recommended staffing and costs to the Department"s proposed One and One Response Program.

Table 4.2.4
Cost Comparison of Current Staffing Model, Proposed One and One Response Staffing Model and Recommended Alternative Staffing Model

Our recommended staffing model, which combines the Department"s proposed One and One Response model with a BLS ambulance tier and 10-hour ALS ambulances, would cost approximately $83,327,404 in salaries and benefits, which is $642,958 less than the salary and benefit cost of the current staffing model of $83,972,362. Our recommended staffing model is $1,284,699 less than the estimated salary and benefit cost of $84,612,103 of the proposed One and One Response staffing model. This cost savings estimate of $1,284,699 may be offset somewhat by the increased hourly overtime cost of firefighter staff assigned to 10-hour ambulance shifts. Although the biweekly pay rate of firefighter staff assigned to 10-hour and 24-hour shifts is the same, the hourly pay rate is greater for staff assigned to 10-hour ambulances than to 24-hour ambulances. The work week for staff assigned to 10-hour ambulances is 80 hours compared to the work week for staff assigned to 24-hour ambulances of 96 hours. However, the overtime costs resulting from the assignment of WDO for an entire 10-hour ambulance shift would be less than the assignment of WDO for a 12-hour watch (one half of the 24-hour ambulance shift) and for a 24-hour shift due to the difference in the number of scheduled hours.¹⁷

Under the proposed One and One Response model, the Department would deploy 19 ALS ambulances on a 24-hour basis and approximately four 10-hour ambulances during daytime and evening hours. During times of peak medical call volume, the Department would deploy approximately 23 ALS ambulances. However, our analysis of FY 1999-2000 CAD data shows that, between 12:00 a.m. and 8:00 a.m., 98.4 percent of the total dispatches to Code 3 and life-threatening calls in a given hour require 13 or fewer ambulances. Therefore, we propose that the Department deploy sixteen 24-hour ambulances. Of these sixteen 24-hour ambulances, we recommend that the Department deploy 13 of these sixteen 24-hour ambulances as ALS ambulances to respond to Code 3 and life-threatening medical calls, and consider deploying three of the sixteen 24-hour ambulances as BLS ambulances to respond to Code 2 medical calls. In addition, we recommend that the Department increase the number of ALS 10-hour ambulances deployed during times of peak medical calls from approximately four 10-hour ambulances under the Department"s proposed One and One Response Program model to seven 10-hour ambulances. Our recommended model would allow the Department to deploy 20 ALS ambulances during times of peak medical call volume to respond to Code 3 and life-threatening medical calls¹⁸ plus three BLS ambulance to respond to Code 2 calls, totaling 23 ambulances during periods of peak medical call volume. The Department would be able to achieve the same level of emergency medical service delivery as in their proposed One and One Response Program model and reduce costs.

Our proposal would result in the scheduling of 16 ambulances during the hours from 12:00 a.m until 8:00 a.m., which is three fewer ambulances than the 19 ambulances proposed by the Department under the One and One Response Program. Because the Department would deploy three fewer ambulances, the workload per ambulance between 12:00 a.m and 8:00 a.m. would increase. Based on the FY 1999-2000 CAD data, we estimate that the average number of dispatches per ambulance for the eight-hour period between 12:00 a.m. and 8:00 a.m would increase by 0.65 dispatches per eight hours, or 18.75 percent, from 3.47 dispatches per ambulance per eight hours to 4.12 dispatches per ambulance per eight hours. We estimate that total unit hour utilization per ambulance for the eight-hour period between 12:00 a.m and 8:00 a.m. would increase by 15 minutes per ambulance per eight hours, from one hour, twenty minutes, and thirty seconds, to one hour, thirty-five minutes and fifteen seconds.

Because our recommended model uses 908 FTEs compared to 921 FTEs in the Department"s proposed One and One Response Program, 13 additional FTEs would be available to back-fill positions. By freeing-up 13 additional FTEs, the Department would have more flexibility in staffing ambulance and engine posts.

Our recommended model would also distribute workload more evenly among ambulances by deploying more ambulances during periods of high medical call volume and allowing the Department to allocate more ambulances to neighborhoods with high medical call volume. Additionally, the productivity of each ambulance would increase, because 10-hour ambulances are not limited by unit hour utilization ratios and therefore, can respond to a greater number of medical calls than 24-hour ambulances, when averaged by the hour. However, the Department would need to meet and confer with the employee organizations to assign firefighter/paramedics (H-3) to 10 hour shifts.

Conclusion

The Department has incurred $2,471,851 in annual salary and fringe benefit costs for 36 new positions to staff four additional ambulances since FY 1999-2000. Since FY 1999-2000, although workload per ambulance has declined, workload continues to be unevenly distributed among ambulances and ambulance response times have not shown consistent improvement.

The Department has identified the need for more opportunities for firefighters to serve as Emergency Medical Technicians(EMTs) on ambulances and for paramedics to work in suppression, and for better working conditions. Both the Basic Life Support (BLS) Ambulance Pilot Program and the proposed One and One Response Program were designed to address these issues. Although the One and One Response Program does not increase the number of FTEs allocated for emergency medical services, the change in configuration of the FTEs would result in annual increased salary and fringe benefit costs of approximately $641,740.

The Department"s proposed One and One Response Program would deploy 19 Advanced Life Support (ALS) ambulances 24-hour, although the actual medical call volume varies greatly by the time of day. We recommend, when the Department implements the proposed One and One Response Program, that the Department deploy sixteen 24-hour ambulances. We recommend that the Department deploy 13 of the sixteen 24-hour ambulances as ALS ambulances and consider deploying three of the sixteen 24-hour ambulances as BLS ambulances. In addition, we recommend that the Department increase the number of 10-hour ambulances during times of peak medical call volume from approximately four ambulances under the Department"s proposed One and One Response Program to seven. Our recommendation would result in an annual cost savings of approximately $1,284,699 compared to the Department"s proposed One and One Response Program, and would distribute workload among ambulances more evenly. Our recommendation would also free-up 13 additional FTEs.

Recommendations

The Fire Department should:

4.2.1 Deploy sixteen 24-hour ambulances and seven 10-hour ambulances when implementing the One and One Response Program. We recommend that the Department deploy 13 of the 16 24-hour ambulances as ALS ambulances and that the Department consider deploying three of the 16 24-hour ambulances as BLS ambulances.

4.2.2 Meet and confer with the respective employee organizations to implement 10-hour shifts for covered employees assigned to 10-hour ambulances.

4.2.3 Submit quarterly reports to the Emergency Medical Services Agency (EMSA) and the Fire Commission, evaluating the performance of the One and One Response Program, including ALS response times, number of ambulance and engine dispatches compared to number of medical events, workload distribution by ambulance, and attrition of paramedic staff.

4.2.4 Submit an annual report to the Board of Supervisors, as part of the annual budget review, evaluating the costs and benefits of the One and One Response Program, including sick leave and overtime use, ALS response times, and number of dispatches compared to number of medical events.

Costs and Benefits

The Department has incurred $2,471,851 in new annual salary and fringe benefit costs for creating 36 new positions and proposes to incur $641,740 in additional salary and fringe benefit costs for implementing the One and One Response Program. Our recommendation to deploy sixteen 24-hour ambulances and seven 10-hour ambulances would result in cost savings of approximately $1,284,699 when compared to the Department"s proposed implementation of the One and One Response Program.

¹ The Department defines "response times" as the amount of time required for the Department to respond to an incident, including both queue time (or the time that the call is held in the Communications Center) and roll time (or the interval between the time of dispatch and the time the unit reports arrival at the incident). Because the Department measured queue time differently at different times, our report uses response time data for FY 1999-2000 and FY 2000-2001 (through March of 2001).

² Code 2 calls are for less emergent medical conditions which allow for slower ambulance response times and Code 3 calls are for emergency medical conditions which require an immediate ambulance response.

³ The Department has approximately 15 paramedics (Class 2532) who did not convert to a firefighter classification.

⁴ "Improving the Utilization of Resources in a Busy Urban Emergency Medical Services System: 12 Month Report on BLS Ambulance Pilot Program Performance", prepared by San Francisco Fire Department EMS Division and presented to San Francisco Department of Public Health, July 31, 2000.

⁵ Memorandum from John Brown, MD, EMS Section Medical Director, Department of Public Health, to Chief Robert Demmons, San Francisco Fire Department, April 19, 2000.

⁶ "Improving the Utilization of Resources in a Busy Urban Emergency Medical Services System: A Proposed Pilot Study", prepared by San Francisco Fire Department EMS Division and presented to San Francisco Department of Public Health, July 14, 1998.

⁷ According to the Department, ALS trucks will initially be deployed to provide fire truck experience to firefighters/paramedics. The Department has not yet decided if the ALS trucks will be deployed permanently.

⁸ "Rapid Paramedic Response System", report prepared by the Fire Department and presented to the Fire Commission, April 26, 2001.

⁹ In FY 1999-2000, BLS ambulances were dispatched 7.57 times per 24-hour shift and ALS ambulances were dispatched 9.97 times per 24-hour shift, for a weighted average of 9.61 dispatches per 24-hour shift.

¹⁰ Memorandum, dated July 7, 2000, prepared by Russell McCallion, Operations Section Chief, EMS Division.

¹¹ "Progress Report" prepared by Robert L. Petrucci, Graduate Intern, SFFD EMS.

¹² Data obtained from the Computer Aided Dispatch (CAD) data report for FY 1999-2000.

¹³ The average annual response times presented in Table 4.2.3 are based on monthly response time averages for the period from July 1, 1999 through March 31, 2001, provided by the Department. Average annual response times derived from monthly average response times will vary from annual average response times derived from total response times for the year. For example, based on FY 1999-2000 CAD data, average Code 2 response times based on total response times for the year were 20 minutes and 31 seconds compared to 20 minutes and 29 seconds in the table above, and average Code 3 response times were 10 minutes 50 seconds compared to 10 minutes 48 seconds in the table above.

¹⁴ In March 1999, the Fire Department received a supplemental appropriation of $2,047,526 to implement the BLS Ambulance Pilot Program. This additional funding was for 18 new firefighter positions that the Department considered necessary to staff the four BLS ambulances with firefighter/EMT positions and for overtime costs for training firefighters to provide BLS service and for back filling fire suppression positions to staff the BLS ambulances. The Fire Department received 18 additional new positions in the FY 1999-2000 budget, for a total of 36 new positions.

¹⁵ The proposed One and One Response Program will increase the number of H-2 positions assigned to ambulances, resulting in an 8 percent differential in pay.

¹⁶ Under the Bronzan Act, enacted by the California State Legislature in 1981, counties are required to competitively bid for EMS services if they substantially change the manner and scope of providing such services. According to the City Attorney"s Office, whether the proposed BLS ambulance tier would constitute a "substantial" change in the manner and scope of providing services has not been tested in Court and therefore, the legal impact of implementing the BLS ambulance tier is not known.

¹⁷ As an example, the hourly overtime rate for an H-3 firefighter/paramedic scheduled for 80 hours per pay period at step 5 is $53.18 per hour, which is $7.99, or 17.7 percent, more than the hourly overtime rate of $45.19 for an H-3 position scheduled for 96 hours. However, the total cost to pay WDO for a 10-hour ambulance shift is $531.83 (10 hours times $53.18), compared to the total cost to pay WDO for a 12-hour ambulance watch (one-half of a 24-hour ambulance shift) of $542.30 ($45.19 times 12 hours) and for a 24-hour ambulance watch of $1,084.59 ($45.19 times 24 hours).

¹⁸ Our review of the FY 1999-2000 CAD data shows that Department dispatched more than 20 ALS ambulances in a given hour on only three occasions (or 0. 8 percent of dispatches).